In 1995, the National Committee for Quality Assurance began the process of developing quality performance measures for diabetes care, which have become more sophisticated with time. Diabetes was one of the first conditions for which quality measures were developed because many disease-related factors can be quantified.
Impact of Diabetes Quality Measures
In the July 2011 issue of Diabetes Care, my colleagues and I published a consensus statement sponsored by the American Diabetes Association on the importance of diabetes quality measures. In our analysis, we found that diabetes care has improved dramatically since 1995. For example, the median national A1C goal was 8.6% in 1995, but it is now around 7.0%. Median systolic blood pressure and LDL cholesterol measurements have also dropped substantially. Physicians, most notably primary care physicians but also diabetes educators and endocrinologists, should be largely credited for these improvements because they have changed their approaches to managing the disease. It’s clear that quality measures for diabetes are here to stay and have contributed to at least some of the momentum toward improved care in recent years.
Quality measures for diabetes are here to stay and have contributed to at least some of the momentum toward improved care in recent years.
The potential unintended consequences of diabetes quality measures are a cause of concern. Standards of care proposed by the American Diabetes Association indicate that an A1C of less than 7.0% is appropriate for some patients while 8.0% is appropriate for others. The simplest solution would be to set the A1C target at less than 8.0% for quality measures, giving providers flexibility to tailor A1C goals based on individual patients. Financial incentives for clinicians who reach quality targets for nearly all patients are another concern. We must adjust quality measures based on patient characteristics or we could inadvertently incentivize doctors to stop working in low– income, safety-net clinics. This may erode our care delivery system for the most challenging and needy populations.
Future Diabetes Quality Measures
Patient preferences are critically important in the care of diabetes, but understanding the risks and benefits of different treatment goals can be a complicated issue. Patients need to be educated so that they understand risks and benefits of different A1C targets and treatments, and then weigh in on their treatment preferences. Attention to patient preferences should be incorporated into quality measures.
Large employers and CMS are interested in applying diabetes quality measures at the individual physician level. We will likely see movement in this direction in coming years. Another big push is to include measures of resource use to diabetes quality measures. The hope is that resource use measures will encourage clinicians to use the most cost-effective treatment strategies to get their patients to agreed upon and appropriate quality targets.
Key elements of the diabetes outpatient cost equations are frequency of office visits and choice of glucose-lowering and hypertension medications. Telephone and social media-related clinical encounters may substitute some office visits at lower cost if these novel “clinical encounters” can maintain quality of care. Widespread use of outpatient electronic medical records will also accelerate measurement of quality and open the door to new quality measures, such as patient-reported satisfaction, provision of lifestyle advice or education, and identification of depression or smoking status. In the end, such information will collectively help providers improve their treatment of patients and may reduce the burden of diabetes and its complications in many of our patients.
Readings & Resources (click to view)
O’Connor P, Bodkin N, Fradkin J, et al. Diabetes performance measures: current status and future directions. Diabetes Care. 2011;34:1651-1659.
Ryan A, Blustein J. The effect of the MassHealth hospital pay-for-performance program on quality. Health Serv Res. 2011;46:712-728.
Lester H, Schmittdiel J, Selby J, et al. The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators. BMJ. 2010;340:c1898.
American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care. 2011;34(Suppl. 1):S11-S61.
O’Connor P, Sperl-Hillen J, Rush W, et al. Impact of electronic health record clinical decision support on diabetes care: a randomized trial. Ann Fam Med. 2011;9:12-21.